Rural Hospitalists, Part Five: At a Decision Point

Over the past two weeks I've been reviewing the state of hospitalist services in rural communities. In Part Four I revealed that my hospitalist group is folding next month. This leaves me contemplating a number of new job opportunities, which I propose to discuss in this post. Once again, the hospitalist groups and hospitals I discuss below are really composites of a number of different groups and hospitals I have known and loved (to different degrees) over the past few years.

A few basic considerations:

• I am not planning to leave Rural, CA., at least in the intermediate short term (5-7 years). I have a solar roof I'm inordinately proud of and I want to enjoy it. I'm also very fond of Rural and not ready to give up yet.
• I am not ready to jump back into primary care, having given it up only in February. To tell the truth, I miss being a primary care doc but don't think I'll return to it as long as I live in Rural. The reasons for that should be the subject of another post.
• I enjoy hospitalist work and have learned a lot about medicine since I've been involved with the Feelgood group. Inpatient medicine is one of those use-it-or-lose-it areas of medicine. I don't want to lose the skills I have until I'm ready to bow out of hospital work entirely.
• Any decision I make about my hospitalist work will not affect my commitment to maternity care. I will continue providing prenatal care at the FQHC and attending births at Gimbels.
• I never wanted to work at Macys. I knew this before I moved to Rural. If Gimbels isn't able to come up with a new solution to their hospitalist problem, I will join one of the groups at Macys but this means the likelihood of my departure from Rural (at least as a full-time member of the community) in the next 5-7 years.

OK, so what are the possibilities for a slightly shopworn family doctor/hospitalist?

1. JOIN WHATEVER SOLUTION GIMBELS COMES UP WITH TO SOLVE THEIR HOSPITALIST PROBLEM

Gimbels is looking to hire some local doctors to shore up the decimated Feelgood group. If this fails, they will contract with one of the big agencies, affectionately nicknamed Xpress Hospitalists and Flash Rounders. I understand they are not interested in contracting with Hospitals-R-Us. Gimbels would like Feelgood's CEO and CFO (me) to join on as members of whichever solution they chose.

Pros of staying at Gimbels:

• Continuing to dedicate most of my professional time at the hospital closest to my home and dearest to my heart.
• Hospital systems familiar to me, warts and all.
• No need to apply for privileges elsewhere.
• Maintain the "good guy" image of myself with the hospital and its staff.

Cons of staying at Gimbels:

• Feelgood's end date is coming soon and no solution in sight. I don't want to prolong my job uncertainty a minute longer than I have to.
• I would have to submit myself to the leadership of whomever Gimbels brings on to run the hospitalist program.
• Even worse, I might have to continue to provide the leadership in the new hospitalist program.

2. JOIN REVENUE-KEEPERS NEW FULL-TIME HOSPITALIST PROGRAM

RK has been running a very part-time hospitalist program for the last couple of years. They want to expand this program to provide 24/7/365 coverage for their patients in order to maximize revenue and enhance physician recruitment and retention for their practice. Currently, they have 1.5 FTE physicians and would like to hire Feelgood's CEO and myself to bring the total up to 3.5 FTE, which would fall short of a full-time program but bring them significantly closer.

Pros of joining Revenue-Keepers:

• Income is likely to be greater than what I was earning with Feelgood.
• My friend and Feelgood's CEO--a great person--is strongly inclined to join RK and I would love to continue working side by side with him.
• RK's management is very smart and motivated, which will make a nice change from my experiences with Gimbels.
• Stroke to my ego: RK is a group internal medicine practice, and they are very enthusiastic to work with me--a family doctor--because I have a good reputation in the medical community.
• Continuing to work with a locally-run program, which fits with my ideals of keeping leadership and revenue within the community.
• RK has a large (8-10) reservoir of internists who can fill in the gaps in the hospitalist schedule until a full roster of hospitalists can be hired.

Cons of joining Revenue-Keepers:

• I would have to provide administrative leadership within the group, and it is not clear whether the time spent will be adequately compensated.
• RK's hospitalist group would still be understaffed at 3.5FTEs, so I would be joining yet another understaffed group with the potential to collapse if they cannot recruit additional physicians.
• The stroke to my ego mentioned above is also a source of indignation. The CFO of RK said, "Well, whenever we've run short of staff in the past, our partners have said 'Oh god, we'll have to get a family doc,' but they didn't say that of you!" Talk about being damned with faint praise. I had to sit on my hands to prevent my middle finger from popping up. I will not tolerate being an ugly stepchild in any organization.
• Joining a private practice with a private group mentality. RK is very unwilling to take on any responsibility for unassigned patients, and have referred to the many Medicaid patients who turn to Macys for their care as "scumbags." I have grown up believing myself to be a woman of the people, and even though I want to be properly paid for my services, I do not like the idea of removing myself from the pool of doctors who provide expert and compassionate care to the underserved.

3. JOIN HOSPITALS-R-US AS A STAFF PHYSICIAN

Hospitals-R-Us, a national medical staffing agency, has been running the main hospitalist program at Macys for several years. Most of the consultants I've talked to think Hospitals-R-Us are doing a good job, although some doctors think they've bitten off more than they can chew and are overworked. Hospitals-R-Us have made me an offer and seem enthusastic to have me join their team.

Pros of working for Hospitals-R-Us:

• Absolutely no administrative responsibilities at all.
• Current staff physicians are a mix of family doctors and internists. Hospitals-R-Us pride themselves on being "specialty blind."
• Current staffing appears to be adequate and ensures a firm shift change at 7am and 7pm daily.
• Highest guaranteed salary of all the programs I have described, for full-time commitment.
• Potential opportunity to learn how a large staffing company works, which might help me learn more about healthcare management.
• Continuing to care for the full spectrum of patients in our community, while being paid well to do so.

Cons of working for Hospitals-R-Us:

• Being a cog in the corporate machine.
• Consistently high volume on their hospitalist service, which would be stressful on a regular basis.
• Alienating the doctors at Revenue-Keepers, potentially closing a door to that employment opportunity if Hospitals-R-Us doesn't work out.
• In-house overnight shifts, the downside of having a firm shift change time.

WHICH FACTORS ARE MOST IMPORTANT TO ME?

In no particular order:

1. Money, of course. I never said I was a saint. I know one surgeon who says, "I'd do my job even if they didn't pay me," but I'm not as good a person as he is. If they didn't pay me to be a doctor, I'd have to do something else because I have to earn a living. The practical part of me thinks I should go for the job which would pay me the most money for the least amount of work. Although Hospitals-R-Us runs a busier hospital service than Revenue-Keepers or Gimbels, they also don't require me to do any administrative work whatsoever. 

WINNER (TWO POINTS): HOSPITALS-R-US.

2. Community. I'm not a saint, but I'm not evil either. I would much rather stay with a community-run operation than work for a big outside corporation.

WINNER (TWO POINTS: REVENUE-KEEPERS. Gimbels might score here if they put together a local solution.

3. Professional development. I never had much interest in business until I finished residency and realized I needed to have an understanding of how money gets made and distributed within business structures in order to survive. I'm giving some thought to pursuing another professional degree, but until I decide, I'd like any job I take to provide the opportunity for me to observe the way a business works. Revenue-Keepers would offer the opportunity, although I'd have to be actively involved with running the thing to take advantage of it. Hospitals-R-Us would permit me to be more of a passive observer; they offer CMEs in healthcare management, etc. and I could pursue an executive track after a few years if I wanted to.

TIE: REVENUE-KEEPERS (ONE POINT), HOSPITALS-R-US (ONE POINT).

4. Sanity. This is one of those vague qualities that are so important to making a job decision. What I mean by sanity is minimal hair-pulling or nail-chewing in my daily working life. I exhibit those behaviors whenever I have to attend a million meetings, distribute information to co-workers when they already have access to the information on email but refuse to check it, or put up with more than the usual irritations from hospital administration. I also use it to refer to how much work I am compelled to take home with me and how much my work life encroaches into my free time. There isn't much sanity working anywhere in Rural, but in writing this paragraph I realize a lot of insanity relates to the amount of administrative work I have to do and how often I have to run back to the hospital to help out a colleague. Hospitals-R-Us promises the most sanity thanks to absence of administrative responsibilities and a firm start/end time for shifts.

WINNER (TWO POINTS): HOSPITALS-R-US.

5. Friendship: I mentioned earlier my friendship with Feelgood's CEO. This has been one of the few saving graces of the whole disaster at Gimbels and I'm grateful to him for making the whole experience tolerable and for teaching me a lot about grace under pressure. He really wants both of us to go to Revenue-Keepers. If I don't join him, it will make the arrangement much less favorable for RK and for him. I know this because we've talked about it. Yet, being the decent and kindhearted man that he is, he has told me he won't harbor any bad feelings if I choose Hospitals-R-Us. But I know how things are. If I don't join RK, we'll grow apart and that makes me sad. On the other hand, my mentor, who is one of the pulmonologists, is very strongly in favor of my joining Hospitals-R-Us so that balances out the equation somewhat.

TIE: REVENUE-KEEPERS (ONE POINT), HOSPITALS-R-US (ONE POINT).

WHERE I STAND RIGHT NOW

Undecided, obviously. One thing is certain: there is practically no reason to stay at Gimbels, other than misplaced loyalty and the remote possibility their administration will come through with a really great program that is ready to go in thirty-nine days when Feelgood's contract ends. But the arguments for Revenue-Keepers and Hospitals-R-Us are almost equally balanced, although each has its own set of strengths and weaknesses. So I'm undecided, although I think a lot of things will become clearer as Revenue-Keepers hammers out its plan. So stay tuned.

One gratifying thing: I will be working, one way or the other, because I have two job offers. There is always work to do in medicine.

Comments

[Beth]

I've gone back and read your 'trilogy in five parts' (as it were) and it's all very interesting to me. I'm a third-year peds resident who will be doing a chief year next year and then hopefully working as a pediatric hospitalist in the hospital I'm currently in. I've wanted to be a hospitalist since I was an intern, mostly because I can't see myself in private practice or in outpatient medicine and I don't want to do a fellowship (although, we now have a forensic peds fellowship, which could be interesting). But I digress. I've only started to think about all the administrativia that comes with an actual job. Although I'll be working in an urban area, a lot of what you are talking about applies to me. I'm glad I stumbled on your blog (what the hell took me so long?!) so I'm interested to see what happens.

[Theresa]

Hi everybody,

Enrico, your feedback is always helpful. As for my preference for local organizations, I think it goes back to my woman-of-the-people philosophy, which has been pretty iffy so far at advancing my own interests.

Anonymous, HRUS does not make a retirement match. In Part 3, I spelled out the compensation packages. HRUS provides $25,000/year if a doc is full time (14 shifts/month) and this additional "bonus" compensation is supposed to be used for health insurance/retirement funding or whatever you want. You have to EARN it, however. None of the options match.

Cancerdoc, I think getting my dander up about the "slight" is silly after all. I know all these groups need WARM BODIES and whether those bodies are IMs or FPs matters not a whit if they can get the job done. In Rural, I am known as a really good hospitalist; my two IM colleagues at Feelgood say I'm the best in the group, which is overstating the case, but still. So I feel pretty confident that the FP thing would not be a barrier in any way. I just wish RK hadn't made that obnoxious backhanded compliment.

As for HRUS, they are bigger but not by much. They do have a reservoir of doctors outside the area who could fill in on locum basis.

Will update once things are a bit clearer.

[CancerDoc]

I am very impressed with your writing abilities and your ability to analyze. You might consider medical management....some day :D

I don't know if you are looking for in-put, but like Enrico, the HRU sounds better...at least in the manner that you have presented it.

Local politics are local politics, and you already aware the of "slight" that seems to be built into the RK group yet alluded to the fact that they will expect you to provide (uncompensated) administrative duties. Also, you will be moving into yet another under-staffed group that might potentially fail. All of those seems like downers. Big downers. Granted, some slights will always be there. In my community there are some pre-existing slight directed at me. I will always have to deal with those, but I certainly wouldn't have joined a practice that treated me that way.

Not listed, but assumed is that the HRU is a much larger group. (How large?). I am assuming that if in a pinch, they can provide staffing from a larger pool and are less likely to cave.

Good luck with your decision.

[anonymous]

i'll disagree with above poster. being a cog in the machine can affect your ability to deliver care. there are more rules to follow, more meetings to attend. i'm not saying it is the wrong thing, particularly if the money is a lot lot lot greater (do they have a retirement match)?

being in a large corporation however, does afford you the opportunity to learn at least one way to do things that seems to be working. i'm going to disagree that you need a degree to learn those things, you seem to be doing just fine learning by doing and observing on your own. you'll have more support in the either of the new structures. the potential drawback, of course, is that the lessons you learn you may have to apply elsewhere (noncompete?-i know you are in california but they sometimes have effective noncompetes under other names).
i wouldn't worry about whether they have a bias against primary care family med unless you think it is irrational and insurmountable. if you do good work, then they will be educated and can change their views.
good luck

[enrico]

My vote goes to HRUS. "I would much rather stay with a community-run operation than work for a big outside corporation." Why? Your real contribution to the community comes from your helping the patient population, not from the arbitrary altruism of whether the same-currency-value dollars are drawn from a local business or from an account in NYC. Your mark in the medical community will be the same no matter how you are employed behind the scenes in Rural, so don't sell yourself short.

You've already been "schooled" the hard way in business matters by dealing with what you've already written about--why would you want to continue down a path that is going to make you do more of the same on terms that aren't yours? In other words, fine if you want to leverage your hard-gained knowledge, but do it building your OWN service in the future, not constantly patching someone else's for questionable reimbursement. Like you were alluding, you aren't Mother Theresa. *wink* *nudge* LOL!

Seriously though, if a CHE or something is something you want to go for, seeing things w/a national agency and potentially leveraging their $$ for continuing ed. and moving up those ranks (just a possibility) affords more choices than more of the same. Unless you think that more local "trial by fire"-style learning administration on the job will net you more/faster knowledge...only you can answer that one.

So I guess in the end I didn't say anything helpful, but I typed it all, so I'll hit "Post" anyway. ;)